To submit your completed form, you can send it via email to service@davisvision.com or fax it to 1.800.234.5678. Alternatively, submit through your member account on davisvision.com. For physical submissions, mail the form to Davis Vision at 123 Vision Way, Suite 100, City, State, ZIP. For best results, ensure all information is accurately filled out before submission.

Important dates for 2024 and 2025 include yearly benefit renewals. Members should check eligibility for eye examinations and eyewear at the beginning of each coverage year.

The purpose of this form is to provide members with a comprehensive understanding of their vision care benefits. It helps facilitate access to essential services such as eye examinations, lenses, and frames. This form also serves to streamline the process of utilizing the benefits for members and their dependents.

• 1. Member ID: A unique identification number assigned to each member.
• 2. Name: The full name of the member or dependent seeking services.
• 3. Date of Birth: Birth date of the member or dependent.
• 4. Provider Information: Details regarding the selected vision care provider.

If the form is not submitted, members may miss out on accessing their vision benefits. Delays in receiving necessary eye care services can occur. It is crucial to ensure timely submission for uninterrupted coverage.

• Missed Benefits: Failure to submit may result in lost eligibility for certain services.
• Service Delays: Potential delays in receiving eyewear and eye care.
• Increased Costs: Members may incur out-of-pocket expenses without the form submission.

• 1. Enrollment: To enroll in vision benefits and ensure coverage before appointments.
• 2. Claims Submission: For submitting claims for out-of-network services.
• 3. Service Updates: To update any changes in personal or dependent information.